DONATE TODAY

iPAD Navigational Planner

Islands Against Cancer, Inc.’s iPads are provided on loan, along with a IT Advocate to assist with the set up and stream-lining to place the tools needed for you to access and manage your care from one device.

Please agree to the terms listed in the form below. We will review your application and you will be contacted by our office regrading next steps.

Request for IAC Navigational iPad
Islands Against Cancer, Inc. (IAC, Inc) provides a iPad for loan outfitted with apps tailored to your specific needs.
Please enable JavaScript in your browser to complete this form.
Name
NA if not applicable
NA if not applicable
NA if not applicable
You attest and certify to Islands Against Cancer, Inc. and its agents that the information provided in your application is complete and accurate. You understand that, and consent to, your reported financial information being verified by an audit as deemed necessary by Island against Cancer, Inc. Islands Against Cancer, Inc., and its authorized third-party agents, such as credit monitoring companies, may use your demographic information, including but not limited to your social security number, date of birth, name, and address in order to estimate your income in conjunction with the eligibility process. You understand that Islands Against Cancer, inc., and its authorized third-party agents, reserve the right to ask for additional documents and information at any time. As a soft credit inquiry, this does not impact your credit score. You further understand that any false or incomplete information provided by you to Islands Against Cancer, Inc. could unduly harm your application process, Islands Against Cancer, Inc., its reputation, and its tax status. You also understand that if Islands Against Cancer, Inc. becomes aware of any inaccurate information or fraudulent activity relating to your application, all services may cease. You understand that you are free at any time to switch providers, practitioners, suppliers, or treatments for your diagnosis without affecting your continued eligibility for Islands Against Cancer's assistance. You understand that you are not guaranteed or promised assistance. Any services or assistance Islands Against Cancer, Inc. may provide is limited to the terms and conditions established by Islands Against Cancer, Inc. Islands Against Cancer, Inc. reserves the right at any time, and for any reason without notice, to modify the eligibility criteria or modify or discontinue any support services assistance. Limitation of Liability: You agree that Islands Against Cancer, Inc., our sponsors, and our donors shall not be liable for any damages of any kind, without limitation, arising out of or in connection with you receiving navigation support, financial assistance, co-pay relief, or other value-added benefits or services provided as a part of this program. Patient Attestation: You agree to be fully compliant in taking the drug for which financial assistance is being provided in accordance with your doctor’s directions.
This field represents the enrollee and serves as a valid signature.
In order for you to receive services and support assistance through Islands Against Cancer, Inc., you authorize your physicians, pharmacies and insurance companies to disclose to Islands Against Cancer, Inc. and its applicable contractors, employees, agents and other representatives your personal information. In addition you authorize Islands Against Cancer, Inc. to use and disclose your personal information to Islands Against Cancer, Inc.’s agents, third parties acting on its behalf, credit monitoring companies, or any of your healthcare providers. Your personal information may include, but not be limited to, your name, address, phone number, email address, date of birth, social security number, insurance status and numbers, amount of any financial assistance allocated and dispensed, diagnosis information, and treatment information. You consent to the disclosure of your personal information for the following purposes: (i) to enable Islands Against Cancer, Inc. to determine whether you are eligible and qualify for support services assistance. (iii) to refer you to, or to determine your eligibility for, other programs, foundations or sources of funding or coverage for your healthcare costs, products and services; (iv) to facilitate the audit or review of Islands Against Cancer, Inc.’ operations; and (v) to enable Islands Against Cancer, Inc. to manage its patient support services assistance programs. You understand that your personal information that is disclosed may be re-disclosed by the recipient and no longer protected by federal or state privacy regulations and laws. You consent to Islands Against Cancer, Inc. re-validating your personal information. You consent to Islands Against Cancer, Inc. electronically disclosing your personal information to third parties as permitted or required by law. You may revoke this consent at any time by mailing a signed letter of revocation to Islands Against Cancer, Inc.’ Privacy Officer at 863 Stiles Drive, Charleston SC 29412 or emailing the written consent to Islands Against Cancer, Inc.’ Privacy Officer at the following email address: [email protected] and/or call (843) 327-0813. Revoking this consent will not have any effect on actions that IIslands Against Cancer, Inc. took in reliance on the consent before it received notice of your revocation. If you revoke this consent, you will not be able to receive future support services assistance through Islands Against Cancer, Inc.. However, your applicable healthcare providers and insurance companies, who are disclosing the information to Islands Against Cancer, Inc., may not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs this consent. This consent expires six years from the date that you last receive assistance from Islands Against Cancer, Inc., if not revoked sooner.
This field represents the enrollee and serves as a valid signature.